ZDoggMD (singing): I don’t wanna wait for the audience to come in and I’d like to start the cast who could it be-

Tom H.: No, Z, you, like, have to wait.

ZDoggMD (singing): I don’t wanna wait for the audience to come in, but they are here so let’s start talkin G…

ZDoggMD (no longer singing): Alright, here it is, guys. I’m really excited we’re doing another episode of Tribe Teach. If you saw our episode on alcohol withdrawal, you will know what you are in for and that is- hit me Logan- SCIENCE! It’s gonna be dope. ‘Cause today we’re talking about… dope! The chronic, the ganja, reefer. The dankest of the dank, the stickiest of the icky, the good stuff.

Tom H.: Kush. Straight kush, y’all. S’up?

ZDoggMD (swaying as if to music)

Logan: There’s no music playing. What are you doing?

ZDoggMD: Oh, well I heard it in my head ‘cause I was like (singing) rollin’ down the street/smokin’ indo/sippin’ on gin and juice/laid back. (not singing) With my mind on the paper and the paper on my mind. Okay, so check it out. Many, many, many people have asked me “ZDogg, what do you think about medical marijuana? What do you think about cannabis legalization? Are there problems with it? Does it cure cancer? Is it the bomb diggity?” Aaand to all of that I say, yes. Uh- except for the cancer part. Uhhh- there’s no evidence it cures jack crap.

Tom H.: Well, this is the problem with weed because everybody has their own thing to tell you about weed. It’s, like, “Dude, weed is great for headaches.” And you smoke it and it gives you a headache. And they’re, like, “Dude, weed is great for relaxation.” And you smoke it and you’re anxious as hell. And then they’re, like, “Dude, WEED is great for the movies!” And you go to the movies and you have a pretty awesome time. That one’s indisputable.

ZDoggMD: I- I’m not gonna lie. Ummm… I may have seen “Winged Migration” under the influence of the very vegan cannabis uh- uh- uh- herb, sativa. Uh- And I will say it was the greatest movie I’ve ever seen until I sobered up halfway through the movie and was, like, this is lame. It’s a buncha birds going foo foo foo foo foo. Anyways, sooo when people talk about any kind of drug, legal or illegal, and cannabis is now legal in several states. It’s still a federal crime to imbibe the ganja, Schedule I drug, difficult to study. So in order to understand more about it you have to take some degree of clinical experience, like, “What’s going on in the field?”, “What are doctors and nurses seeing in patients who are using cannabis?”, and you have to take some anecdotal stuff and then take what little science we have behind that and try to paint a picture of what’s going on. And while doing that over decades, what has emerged are a few interesting things. It is pretty clear that cannabis at lower doses in particular, the cannabinoid effect, seems to have an antiemetic property. Meaning it will uh- help with nausea in many people. And there’s a lot of speculation for why this is. There’s CBD-1 and CBD-2 receptors. There’s stuff that happens centrally AND peripherally with those receptors. And it’s been speculated that it could be a mix of those things in addition to some anxiolytic component. Anxiolytic means destroying anxiety. So a lot of umm- nausea is what we call supratentorial: above the tentorium in the brain. Meaning, sort of conscious brain. So worry, anxiety, sort of those mental processes. And if you can calm that- which is why lorazepam- one of the benzodiazepines related to alcohol we talked about in alcohol withdrawal the other day- why that particular medicine seems to have some effect on nausea, particularly, like, chemotherapy nausea, people who are anxious. Sort of, they’re worried about it and they’re getting nauseous? A little Ativan takes that edge off. Now cannabis may have some component of that as well.

Tom H.: Now, if I was gonna Bro Science this, I would be, like, “Bro? So we have CBD receptors in our brains? That means, so natural and we should totally be doin’ it.”

ZDoggMD: Yes. You should say that because anandine receptors, cannabinoid receptors, those kind of things, they are a natural part. But that- that’s how all drugs work. So whether they’re natural or not, you know we have some- gate, pathways for LSD, lysergic acid diethylamide. Doesn’t mean you should be dropping acid all day. So it’s really a question of, like, “What is the safety profile of the drug? What are the side effects? What are some unusual syndromes?” And one of the things that has emerged is a paradoxical syndrome that has been called a variety of things, but let’s see what the popular press calls it. Logan, can you pull up the picture of the smoking? There he is. This was in The Atlantic. I saw it today. “WILL SMOKING POT MAKE ME VOMIT FOREVER?”-ever-ever-ever-ever-ever… Tad says “Clickbait! It’s clickbaiiit-”

(laughter)

Tom H.: I like that Tad now sounds like Gilbert Godfrey.

ZDoggMD: Taad… you know, in my mind Tad IS Gilbert Godfrey.

(laughter)

ZDoggMD: Just with very, very tight buttocks. Look at this. Look at his buttocks.

ZDoggMD: Ummm… Anyway (laughter) Anyway, soo this is obviously a clickbaitey- uh- let’s throw it up again while I talk about it if you don’t mind, Logan. This is a very clickbaitey way to get people to read your article. “Will smoking pot make me vomit forever? Cyclic vomiting syndrome is on the rise among adults and marijuana use may be partially to blame.” And in this article Katie Heaney talks about her own uh- refusal to do drugs until late in life because of D.A.R.E. the uh- Drug Abuse Resistance Education, which (laughter) data seems to show, it’s taught… it was founded in 1983 and for a time it was taught in up to 75% of American middle and high schools. It doesn’t work. (laughter)

ZDoggMD: Exactly. So students who’ve undergone the program are just as likely to use drugs as those who haven’t and may be even MORE likely to drink and smoke cigarettes. So… D.A.R.E. to stay on drugs. Ummm…

Logan: Thanks, Nancy.

(laughter)

ZDoggMD: But in the- but in the process of- of talking about D.A.R.E. she says, well, she started doing- smoking weed later in life. Uh- tried it out and found that it didn’t cause problems for her. But then she started getting scared because she heard about something called Cyclic Vomiting Syndrome. So, again, what we’re gonna address today is this particular described syndrome that may or may not be related to marijuana ingestion. In particular chronic, long standing, cannabis use. Uhh- and let’s kind of unravel it, let’s look at one of the papers, and let’s see if it’s something that we want to pay a little more attention to in our patients who have cyclic vomiting, which I’ll talk about. And in- uh- people who think that, you know, chronic long term marijuana use is without complication. So let’s see if that’s really true or if there’s something we can learn from this because it has been documented that, again, short term marijuana use has antiemetic properties, anxiolytic properties, those kind of things. So could it have some medicinal purpose in that way? Sure. Does it have a recreational purpose? Yes. Does it have a down side? Absolutely. You’re impaired if you drive. Ummm… doing too much of it can lead to a kind of an amotivational syndrome which I know you’ve (gesturing toward Tom) not experienced yourself, but you have friends who maybe experienced that.

Tom H.: I’ve short term, like short term…

(At same time) ZDoggMD: Well- Tom H.: That’s-

Tom H.: -like once on the weekends-

(At same time) ZDoggMD: Well- they- they- Tom H.: -every once in awhile or is that like

Tom H.: -you smoke for a period of weeks and then you go off for a period of weeks… or what?

(At same time) ZDoggMD: Well- Tom H.: What is it?

ZDoggMD: You know, this is up in the air, you know, and- and different authorities will define it differently, but one thing you have to remember, guys, is that the active ingre- uh- agents in cannabis are- they- they will oft- they can bind to cerebral fat which means that they have a half life in the human body that’s quite long which is why drug testing can catch uhh- you know, uh- cannabis ingestion, you know, a month out for some people. Especially heavy users. And so, what is the cumulative effect of- of smoking every day on the storage capacity of these metabolites? So getting into this, the way that the- the popular press sort of framed this in this article is talking about, well could it be that this Cyclic Vomiting Syndrome that we’re seeing now in adults- it used to only be in kids- is now umm- a result of increasing use of cannabis? Particularly in the legalized setting. And, what I want to do is, I want to go, because they cite a couple of, like, reviews of reviews. Uhh- papers that aren’t the primary papers. I went back to the original primary paper. Uhhhh- first there was a series and thi- we have to understand first of all- how is the science done? What’s the sort of theory behind why cannabis might do this? And does it actually happen? What do you think, Tad? “I think it’s totally the weed, man. What do you think is in this little red box?” I play with dolls. What?

(laughter)

ZDoggMD: What? Ummm… So going back, one of the first uhh- sort of papers to kind of look at this was something where, it was in Australia because apparently in South Australia at the time there was a considerable liberalization around marijuana so a lot of people were smoking weed. And what they started noticing, doctors started noticing this pattern where, you know, young people would come in with this cyclic vomiting pattern where all of a sudden- and it had a certain series of characteristics- ALL of a sudden, out of the blue, they would start vomiting. And it was often associated with some abdominal pain, usually epigastric, right here, but it could have been anywhere and it would be associated with sweating and just uh- uh- a general, you know, mild anxiety. Often it was associated with weight loss because people wouldn’t eat when it was happening and it would last for some period of time, usually days, and then it would stop. And theeen- it would start again. Uh and that’s why it- it got confused at the time with something that was documented previously in kids mostly, which is CVS, Cyclic Vomiting Syndrome. And in children this is a- a well described phenomenon. Still difficult to understand why because, in children, they’ll just suddenly start to vomit and then they’ll be clear for a few weeks, then they’ll start to vomit again, they’ll be clear for a few weeks. You’ll do a big workup and you won’t find any cause for it. And in the setting of that, it’s often associated in children with migraines. So they’ll have migraines around that. They’ll have migraines later in life. And often it clears up as they reach adolescence. So it can be very distressing, very debilitating for children, but when they started seeing it in adults they said, “Wait a minute. What’s going on? We weren’t really seeing a lot of this before.” And that’s when people- scientists- But this is what science does. They take a series of anecdotes, some experience that they have, and they go “You know what? Let’s try to describe this better. Let’s do a case series. So let’s take a series of people who’ve had this thing happen and let’s study and see what characteristics they have in common and let’s see if we can find a pattern.” And that first happened with Cyclic Vomiting Syndrome and cannabis in ummm- let’s see, when was it? It was 2004 in the very beautifully named journal Gut.

Tom H.: Hey, I got somethin’ to say. Stephanie says if this becomes a regular educational series (laughter) we should call them “Tad Talks.”

Tom H.: Also, I’d just like to say… weed can help with weight loss? Bro, is there anything weed can’t do?

Logan: Bro.

ZDoggMD: (deep breath) It cures everything, bro. It cures everything including caring about the cure for anything.

Tom H.: True.

ZDoggMD: Ummm… So this first series in Australia in 2004, again as sort of a case series, and what they did was they looked at a grand total of 19 patients. They had a very small number. Uh- and of that uh- five refused to consent for the study. ‘Cause they were like, (mimes taking a toke) “Bro, between the puking and the weed, (laughter) I just don’t give a fuck about this trial, man.”

Tom H.: Wait. This was a fourteen person study?

ZDoggMD: Literally it was- it got down to ten. (laugher) Alright. So you have a ten per- now remember this isn’t a randomized control trial so you don’t need a thousand people to get statistical significance. You’re just describing a series of cases. So they start small. Alright. So ten patients and it turns out that umm… they all smoked a ton of weed, they had this cycle- cyclical vomiting illness that looked like cy- yo- CVS, Cyclical Vomiting Syndrome, but it was, as I say, with heavy marijuana use. By heavy meaning like, at least a year of, you know, nearly three times a week weed smoking. Often more than that. So people were regular users. And, by the way, you start to think about chicken and the egg. Like, are they smoking because they’re nauseous?

Tom H.: Right-

(At same time) ZDoggMD: And this is some- Tom H.: Or are they getting-

Tom H.: -nauseous because they’re smokin’ weed?

ZDoggMD: Exactly.

Tom H.: Plus, the people I know that like pot reeeallly like pot. Dude, three times a week is bullshit.

ZDoggMD: Yeah.

Tom H.: They smoke pot all day-

(At same time) ZDoggMD: Yeah. Wake and bake. Tom H.: -every day.

ZDoggMD: Wake and bake. Get high-

Tom H.: Perpetually high.

ZDoggMD: Absolutely. And I think that’s the more- the norm with this syndrome.

(At same time) ZDoggMD: Is what we see. Tom H.: Right.

ZDoggMD: So they looked at these guys and they said okay umm… in all the cases there was chronic cannabis use pre-dating the onset of the vomiting. So it happened before the vomiting. So they kind of tried to rule out “Well, is it chicken and egg?” Well, no. They were smoking weed well before they got sick. Cessation of the cannabis abuse led to cessation of the cyclical vomiting illness in seven cases. So here’s a theory, the weed’s gettin’ you effed up and you’re gettin’ this vomiting. Stop smoking. See if you get better. In seven of the ten cases, that’s exactly what happened. Ummm… TWO of the three cases- Sorry, in two of the cases ummm… Sorry, sorry. Let me read this carefully. So THREE cases, including the published case, did not abstain. So they were like, “Yer not takin’ my weed, bro.” Actually, they were Australian so they were like, “Thas not weed. THIS is weed.” (laughter) And uh- and they continued to ha- to smoke and they continued to have recurrent episodes of vomiting. Everyone who stopped actually stopped vomiting. Now, it turns out the three cases umm… Three cases that had stopped, challenged themselves again with weed. So they were like, “I’m gonna try to smoke weed and see what happens.” And they had gotten better. And guess what? They got worse. They started throwing up again.

Tom H.: Ahh.

ZDoggMD: So, people started to conclude that there’s something going on here and it may have to do with the Chronic. It doesn’t take Scooby Doo to make the association. Again, this is an association. It’s a tiny trial in Australians that don’t count because they’re not real human beings.

(snickering)

ZDoggMD: Ummm… (laughter) Conclu- (singing) How can we dance when our earth is turning (laughter) How do we sleep when our Tad is burning? (not singing) Ummm… Okay, so that was the fiiirrst case series. And this is what happens. People look at a case series and they get interested and they go, “Can we replicate this with more cases? Can we see if there is more we can learn?” And this is what the Mayo Clinic did. So- and I’ve put links to these articles I believe. I may have given you one of the uh- two articles as well as The Atlantic article. So the Mayo Clinic in 2012, I believe, uhhh- did a trial, 98 patients, and they said, “Okay, let’s see if we can replicate this finding.” because they were noticing the same anecdotal stuff in Minnesota where people are high, like, all day, ya know what I’m sayin’?

ZDoggMD: Jesse (The Body) Ventura, man. High AF the whole time he was governor.

Tom H.: Okay, that one I believe.

ZDoggMD: Yeah, I believe it, too. So they went through and they said, “Okay, what is the dillio?” And actually uh- this is what they found. So, they started- they started looking at say cannabis is well known for its anti-nausea effects, and they talk about the- the, you know, the nine patient trials, etcetera. And so they first start the paper by reviewing previous data. And also some of the theories. Now since the first trial, in Australia, thirteen case reports and three small case series showed that uh- there was more of this- Why’s Siri tryin’ ta talk shit right now? Siri, you shut your hole!

ZDoggMD: Back on track. (laughter) So- so in 2009, uh- they started describing these clinical features, long term cannabis use, cyclic vomiting, colicky abdominal pain, com- and ah here’s where it gets interesting because this was reported in the Aussie trial and I think everyone just assumed it was those crazy Aussies being crazy, but it turns out, Tom Hinueber, that every one of these cannabis hyperemesis patients would sit in a scalding hot tub of wa- of bathwater. And they found that it made ‘em feel bettah. And so it’s true that- how can we puke when our bath is burning? (pause) Isn’t that weird? So, this is the thing, they would learn- this wasn’t an OCD thing, it wasn’t a psychiatric thing- they would learn through behavioral experiment. These patients would sit in a scalding hot bath, the hotter the better, to the point where they would burn themselves sometimes. And find relief of their symptoms. So this was part of the constellation. Which is so frickin’ weird, right?

Tom H: Wait… is this during withdrawals from marijuana?

(At the same time) ZDoggMD: No. Tom H.: No.

ZDoggMD: They’re high AF the whole time.

Tom H.: Ah.

ZDoggMD: In fact many of them said that they smoked MORE weed when they had the emesis because they- they’d heard that obviously the weed helps with nausea. So-

(At same time) ZDoggMD: wondering is it a- is it a- Tom H.: -same thing?

ZDoggMD: -withdrawal thing?

Tom H.: Yeah.

ZDoggMD: Ahhh. That’s interesting.

(At same time) ZDoggMD: Maybe there’s- Tom H.: That’s how I was thinking.

ZDoggMD: -some crossover in the mechanism of what’s going on.

Tom H.: Okay.

ZDoggMD: So let’s talk about that. We’ll get to that definitely by the end. So these hot baths, the abdominal pain, the vomiting, and the smoking hella Chronic. Right? So Dr. Dre Syndrome with a little edge of Snoop Dog and hella hot baths. Alright. So they- this is what they did- they took patients with long term marijuana use before the symptoms started. They looked at a history of recurrent vomiting. So now they’re starting to have this recurrent vomiting in the absence of any major illness that might explain the symptoms. So it isn’t, you know, some metabolic derangement. It isn’t pancreatitis. It isn’t liver disease. It isn’t, you know, gastritis. It isn’t gastric emptying problems. All these other things that can cause cyclic vomiting. They rule those out. Okay? And the way that they did this was they looked at Epic, their electronic health record, which was what I assume Mayo uses. I think they use Epic. Anyone from Mayo that knows differently, let me know. ‘Cause this was done at Mayo. And they did a chart review and they said, “Okay, let’s search for these search terms.” You know, marijuana use, cyclic vomiting, blah blah blah blah blah. And then they went and did the biopsy of the chart. They first found 55 patients that met inclusion criteria. Which were the things I just mentioned. And inclusion criteria in a trial, as you guys remember from the last uh- trial we talked about, means these are the cha- the- the things that you need to meet- these criteria you need to meet in order to be included in the trial. And then there are exclusion criteria. In other words, if any of these things are true you can’t be in the trial. So in this case the inclusion criterias were met for 55 patients and then they went through and did a broader search ‘cause they were like, “This idn’t enough. We need a bigger case series.” And they broadened the search parameters in Epic and then they found a few more patients. So they found- let me see here- total, they got to a total of 98 patients. So that’s how they did it. Then they went through and biopsied the chart and they got data about these patients and followed them as long as the chart actually had data for. And this was variable. So some had a little data, some had a lot of data. Since Mayo’s a terrtiary referral center sometimes there wasn’t a lot of follow-up. You’d see a patient for a problem and then they’d go back to their primary somewhere else. So it wasn’t the best data set and that’s one of the limitations of the trial. So 66 patients, 67% of them, were men. Alright. So maybe that’s just uh- so maybe that’s just part of the demographic that smokes more weed uh- or there’s a predisposition in men to have Cyclic Vomiting Syndrome

Tom H.: Nah. My bros get high, dude. My bros get hiiiigh.

ZDoggMD: (laughing) So it’s a- it’s a men thing. Uhhhhh- maybe. (snickering) We’ll call it men-sees. And uhhh- 37% consumed cannabis products for more than two years uh- before the symptoms occurred. So they’d been using it for quite some time. 84 patients, or 86% of them had abdominal pain associated with the nausea/vomiting. So these are just characteristics of these guys. Turns out about half of them smoked. Not many used alcohol. Ummm… so only uh- ten out of the ninety-eight used alcohol because they were too busy getting high uh- to drink. And umm… and this is what they found. It turns out- Oh, and this is interesting, one more characteristic of these guys. 57% of these weed smokers who had Cyclic Vomiting Syndrome had documentations of the effects of hot water bathing on their symptoms. This was actually in the chart. So they would say, “I take a really hot bath and I feel better.” Isn’t that interesting?

Tom H.: And they had all sort of just stumbled onto this on their own?

ZDoggMD: Yeah. So it turns out maybe they heard from a friend or maybe they just discovered that when they take a hot shower the nausea got better and the hotter they made it, the better it felt.

Tom H.: Mmm.

ZDoggMD: So it’s people just… doing what they do which is adapting to chronic illness. And umm… so, you know, what Vader always says, “You don’t know your body! Vader knows your body!” But these guys knew their body. And they knew (laugh) knew that if they cranked up the heat it would feel better. So in the setting of that umm- they did some diagnostic studies in most of the patients. And remember, this wasn’t a prospective study. This was a retrospective case series. What that means is, they looked back at patients that had already been seen for other stuff and then looked at the data they’d already collected in a different way. They’re not going forward and saying, “Okay, let’s do this and this and this and this.” That’s a prospective trial. So in this retrospective trial it turns out that diagnostic studies were done on most of these patients and they were negative for alternative diagnoses. So uh- blood cell counts, glucose, liver biochemistry, pancreatic enzyme levels, CT of the belly, upper endoscopy. So going in with a scope and looking around. And colonoscopy. So they really did a pretty exhaustive thing. And a lot of them, 61% of them, okay? Had gastric scintigraphy, which is a way of measuring how- how fast the stomach empties. So… Imagine this. Imagine this-

Tom H.: Stomach- stomach empties into the colon?

ZDoggMD: Stomach empties into the small intestine.

Tom H.: Okay.

ZDoggMD: And then through the small intest- the duodenum into the small intestine and then you get absorption there and into the colon where a lot of water and electrolytes are reabsorbed and then you poop it out.

Tom H.: Got it.

ZDoggMD: So that’s the path. So, the way it works is this: the gastric scintigraphy measures how quickly does something that they measure get through that stomach out into the intestines and through out to the back. And what they found is most of these cats had NORMAL gastric emptying. And norm- or overly FAST gastric emptying. Often what we see in nausea and vomiting syndromes-

Tom H.: Slow.

ZDoggMD: -is slow.

Tom H.: Yeah.

ZDoggMD: Because it’s backing up. It’s sitting there. You’re not moving. So people with uh- gastroparesis, which is a fancy way of saying a paralyzed stomach, it’s or- or a hemi- almost paralyzed stomach. They’ll, they’ll vomit because it’s not going down.

Tom H.: Right.

ZDoggMD: It just has only to come up. So in THESE cases they saw some of that, like I think- I forgot what the exact number was. 30 perce- uh- sorry- uh 30% had delayed emptying, 15% had rapid emptying, but the majority, 46% had normal emptying. So you couldn’t nail it on slowed gastric emptying.

Tom H.: Right.

ZDoggMD: Which was one of the theories going in. Cannabis maybe slows gastric emptying and maybe that’s the reason why people are vomiting? Maybe that’s also the reason why it helps vomiting in some people? So-

(At same time) ZDoggMD: But it- Tom H.: Yeah.

ZDoggMD: But it turns out this wasn’t the case.

Tom H.: You know, this is really interesting because in high school one time we were gettin’ high in a car and uh- my friend took one hit of the blunt and was like, “UH. Pull over. I need ta throw up!” And we’re all like, “S-ha-ha. Loser.”

ZDoggMD: (laughter) Loser!

Tom H.: We just left him there.

(laughter)

Tom H.: Buut-

Logan: Without the munchies.

Tom H.: It makes me think, like, he probably had some version of CVS.

ZDoggMD: Well, yeah, and there are a lot of people who get vomiting after ingesting high doses of THC, cannabis. And the munchies is a separate thing. Ummm… it may be a central effect on appetite stimulation, but we’ll talk- we may talk about that in a different show.

Tom H.: Mmm.

ZDoggMD: So- so then what they did was interesting. So they said, “Okay let’s see what the follow-up was. What happened to these patients?” Here’s the big weakness of this trial. Follow-up was available in only TEN patients. So 10% of the 98.

(At same time) ZDoggMD: Meaning- Tom H.: Those-

Tom H.: -are the only people that came back?

ZDoggMD: They’re the only people that came back or had documented follow-up. So-

ZDoggMD: You have my calendar, bro. Was I s’posed to be at the My-o Clinic today, man. Oh, mayo… that sounds damned good, dude. Get me a sandwich, bitch. (laughing) I want a sandwich, Tad.

(Kissing the Tad doll)

ZDoggMD: Ummm… So only ten followed up for whatever reason. And three of those did not abstain from cannabis use. They were like, “Hell no, bro.” And they continued to have symptoms. Six of them the uh- so 60% of the ten, stopped using cannabis and noticed a complete resolution of their symptoms. There you go. Very much in line with the Australian data. And the time to improvement varied from one to three months. So… it took at least a month to feel better and up to three months. Now, Tom? When I said that uh- THC and the metabolites of cannabis use can be stored in cerebral fat and other fat?

Tom H.: Mmhm.

ZDoggMD: Is it surprising to you that it might take a month before you see improvement in a heavy cannabis smoker who’s smoking every day for-

Tom H.: Not at all.

(At same time) ZDoggMD: Yeah. Tom H.: Because I used to

Tom H.: -smoke cigarettes and it took a good three months for my brain chemistry to reset after nicotine withdrawal.

ZDoggMD: Now THAT- now I think nicotine is water soluble. I may be wrong. Correct me if I’m wrong. So what happened with you was your brain receptors, your nicotine receptors, might have been differently regulated from chronic nicotine use-

Tom H.: Mmhm.

ZDoggMD: And it took that long for those receptors to remodulate because they’re little proteins and cell membranes and it takes time for them to change.

Tom H.: Yeah.

ZDoggMD: So it might have been that-

Tom H.: But I mean just on the issue of dependency-

ZDoggMD: Right. Right.

Tom H.: I believe it.

ZDoggMD: Sure. Sure. So the question is, is there still cannabis goo floating around in the fat? And it takes about a month to wash out and maybe that explains why that takes so long.

Tom H.: Yeah.

ZDoggMD: So again, we’re speculating a bit, but based on first principles of cannabis pharmakinetics- pharmacokinetics. Alright. So after not using cannabis for only one month, one patient experienced NO symptomatic improvement. So one of them who quit only did it for a month and he didn’t get any better and he started smoking weed again. ‘Cause he’s like, “I’m gonna get high, son.” Umm… and you gotta think. Okay the people who are daily cannabis users, it’s a big deal to stop. They’re dependent on it at least psychologically.

Tom H.: Yeah.

ZDoggMD: And so-

Tom H.: Yeah, there’s gotta be at least some physical, right?

ZDoggMD: Yeah. I- again, people will deny physical-

Tom H.: Lis- Dude, weeed’s not addictive.

Logan: It’s the devil’s grass.

(At same time) ZDoggMD: Devil’s grass (laughing) Tom H.: I just smoke it all day every day because I like it.

ZDoggMD: Yup and cannabis has autonomic effects in real time. So tachycardia without a concomment increase in- concomitant increase in cardiac output. What that means is your heart goes faster (clapping hands together repeatedly) but you don’t increase your cardiac output. So it’s kind of an ineffective fast heart rate. Which is why exercising when you’re very high is probably not a very effective strategy for improving performance.

Tom H.: Tell that to everybody in the NBA. (laughter) Because they’re high AF.

ZDoggMD: (singing) Then I got high-

Tom H.: The NBA doesn’t really test for weed because everyone would fail.

ZDoggMD: Exactly. Exactly. So because 32% of the patients reported cannabis use for less than a year, they think that years of cannabis use are not essential for the diagnosis of this, but rather uh- you know, you can have it even after shorter durations. But in general. So this is what they came up with from looking at this um… this piece. Logan, there’s a graph that I ga- or a chart.

Logan: Boom.

ZDoggMD: There it is.

Tom H.: Hey, real quick-

ZDoggMD: Yeah?

Tom H.: -from Kim Jordan uh- she wants to know, “Would Serotonin Syndrome be the same concept of withdrawal?” I’ve heard about that a lot…

ZDoggMD: So Serotonin Syndrome is less a component of withdrawal than it is an excess of serotonin often caused by a reaction to SSRI medications like Prozac, Zoloft, Celexa, etcetera. Or from other medications that increase serotonin. And there’s classes. MAOI inhibitors are a type of old antidepressant that can interact with certain foods and medications and cause high levels of serotonin. If you’ve ever seen Serotonin Syndrome, it’s terrifying because high levels of serotonin cause blood pressure abnormalities through the roof. You can risk stroke. Your temperature goes up. You need to be in the ICU. You’re often delirious. So-

Tom H.: Yeah.

ZDoggMD: So a little of serotonin is a good thing. A lot is a bad thing.

ZDoggMD: Yes. So actually ecstasy can be associated with a serotonin syndrome and what you see in people who show up in the ER is often a hyponatremia because they have derangements of electrolytes and then they can progress to a serotonin syndrome. This happened to a friend of mine in residency. She was admitted to the ICU with Serotonin Syndrome after trying ecstasy for the first time.

Tom H.: Damn.

(stopped at 30:00 minutes)
ZDoggMD: There you go. MDMA, baby.

Tom H.: Gateway drug.

Logan: Tad’s butt.

ZDoggMD: Tad’s butt. If that doesn’t give you an ecstasy like feeling, nothing will, ladies. (laughter)

Logan: There’s the graph.

ZDoggMD: And men. Alright so there- here’s the graph. So this is what they proposed looking at their case study which is small. To have this diagnosis of Cannabinoid Hyperemesis, right? Which is what they were calling it. The uh- Atlantic article just calls it cannabis related cyclic vomiting syndrome. Doesn’t matter what you call it. This is what it is; you need to have long term cannabis use and long term could be less than a year, according to them. The major features would be; you have this severe cyclic vomiting. So you’re vomiting for some period of time, days, hours, weeks, and then you’re better, and then you’re vomiting again. It gets better when you stop the Chronic, so resolution with cannabis cessation. The relief of symptoms with hot showers or baths. So this is actually a real phenomenon. If you take a hot bath and it gets better. Now a lot of nausea gets better with a nice warm bath, right?

Tom H.: I’ve never known that before. This is my first time learning about that.

ZDoggMD: Yeah. So, but with the weed thing they’re saying this is- the term is pathognomonic. So what that means is, it means, “When you see THAT with THIS, that screams THIS.”

Tom H.: Yeah.

ZDoggMD: That’s like the hallmark of this shit. Pathognomonic.

Tom H.: So that’s basically like a fancy way to say, like, it’s correlated.

ZDoggMD: It’s a STRONG correlation.

Tom H.: Strong correlation.

ZDoggMD: And in fact it’s a little stronger than that. It’s, like, “Now, when you see blood squirting out of a carotid artery, that’s pathognomonic of someone who’s about to die.”

Tom H.: Yeah. (laughter)

ZDoggMD: So it’s- it’s kind of like that.

Tom H.: Okay. I get it.

ZDoggMD: So yeah, yeah, yeah. So umm… (laughter) So back to the- back to the chart if you don’t mind. Umm… abdominal pain is a common symptom. Major feature of that. And weekly use of marijuana was another major feature. Now things that support it might be; you’re younger like most stoners. You have weight loss because a lot of them would lose weight. You have- the- the symptoms are worse in the morning which is interesting. And you have normal bowel habits. ‘Cause when they looked at the series, these guys didn’t have a lot of diarrhea and other problems, constipation. They had normal bowel habits. And the rest of their workup was negative. So that’s what they kind of propose and I think since then there’s been a lot of intellectual masturbation over WHY this might- why cannabis might cause this in some people and not others. So is it a- uh- the way that cannabis is processed? Cannabis contains over 60 active compounds. Could it be something else other than THC?

Tom H.: I saw somebody ask it if was different types of cannabis. Like there’s a lot of talk now that cannabis is getting legalized about indica versus sativa, the amounts of THC in the cannabis, etcetera, etcetera.

ZDoggMD: I believe it’s just the dankest of weed.

Tom H.: Mm.

ZDoggMD: Yeah. In fact that was correlated in the study that those who smoked the dankest Chronic uh- the endo if you will uh- were the most corr- NO! This is the problem with this study. They don’t have that data.

Tom H.: -is you can’t study it and we don’t know what’s in it. It’s all moonshine basically. I think it’s super high levels of THC ‘cause that’s what sells the best so.

ZDoggMD: Tad cam. (singing) “Legalize it dung ta da da dung legalize it dunk dunk dung ta da ah dung” (not singing) Umm… study it at least. So what umm… what has been speculated? So the antiemetic effects of marijuana, we’ve know about those. Now there are receptors of cannabinoi- Cannabinoid 1, CB-1 and CB-2, in the brain, in the central nervous system on the dorsal ganglia, hypothalamus, hippocampus, cerebellum. So all these major areas of the brain.

Tom H.: Oh, real quick?

ZDoggMD: Yeah, yeah, yeah?

Tom H.: Shannon says, “Since my daughter has this ummm… isn’t it bad to stop all at once or should she taper off or should she just stop it all at once?”

ZDoggMD: Oh, excellent question. So what the later papers have proposed. And this is where you get into a bunch of old guys sittin’ around a table.

Tom H.: Yeah.

ZDoggMD: There’s no data on any of this. But what the old guys sittin’ around the table say for helping this is, you stop the weed, but you don’t- you treat them first. And the way you treat this emesis syndrome is you stop the weed, but you also give a- a couple of different classes of medication. One of them is, remember that medicine lorazepam, Ativan? That I was talking about earlier? That’s a benzodiazepine. So that is something that will take away the anxiety component of whatever withdrawal you get from the cannabis and also help the nausea. Because, remember, it’s gonna be a month off the weed before you maybe feel better.

Tom H.: Yeah, but you can’t take a benzo every day for a month. You’ll get addicted to benzos.

ZDoggMD: You can. You can take it as needed.

Tom H.: You’re right.

ZDoggMD: So you feel sick, you take a little bit.

Tom H.: So you have to wait for your symptoms to worsen pretty severely? Then you take one for need?

ZDoggMD: Generally, that’s what they say-

Tom H.: Yeah.

ZDoggMD: And the thing is are you-

(At same time) ZDoggMD: swapping Tom H.: Do you- do you ever worry about

Tom H.: -rebound anxiety on uh- benzodiazepines?

ZDoggMD: 100%

Tom H.: Yeah.

ZDoggMD: Absolutely. That’s why when you get it higher doses and you’re regular all the time on it?

Tom H.: Right.

ZDoggMD: When you take it away you can withdraw the same way you withdraw from alcohol. In fact the benzo withdrawal is the worst-

Tom H.: Yeah.

ZDoggMD: because-

Tom H.: Yeah see I don’t know if I- I’ve taken them intermittently during my life mainly just to party. (laughter) But uh- (laughter) I always found that I had more anxiety after they were over.

ZDoggMD: Yeah, yeah.

(At same time) ZDoggMD: You know I rea- Tom H.: I got relieved for

Tom H.: -like, a period of time and then I got anxious again.

ZDoggMD: Yeah and this is common with any kind of withdrawal from- even short term withdrawal from benzo- Are we- Do we have a signal going through? People are saying this things-

Logan: Yeah, it’s good.

ZDoggMD: It’s good? Okay, good. Umm… So you give that benzo and then another class of drugs are the tricyclic amines, the TCA drugs. Uh- you know Elavil, etcetera, that can help with the anxiety, some of the nausea, depression components coming of the marijuana.

Tom H.: Another question about weed. Uh, Jennifer Marie says, “What about the chronic pain aspect? I’ve been starting to see studies saying that THC/CBD does NOT help chronic pain at all. Thoughts?”

ZDoggMD: It turns out they’ve done some series where it didn’t help. And the question is, did they study it appropriately, is it a big enough series? And I haven’t looked at that data primarily. So I don’t know. Some people swear by it. And I think it’s the anxiolytic component. So when you’re anxious about your pain?

Tom H.: Right.

ZDoggMD: You get high. Although, I’ll be honest (laughs) I get high and paranoid about everything.

Tom H.: Now the ah- somebody told me that, you know, if you’re sick “Hey, man, if you’re sick, you should totally get high. It totally fixes that shit.” So I got high and then I was just like, “It didn’t fix anything but I forgot I was sick for about an hour and a half there. So that was nice.”

Logan: Good advice.

ZDoggMD: (laughing) Oh, science. Uh- so the idea that these receptors are all throughout the brain, but they’re also in the enteric nervous system. The enteric nervous system are the nerves in the gut and there are, like, a shit ton of nerves in your gut. And it turns out there are receptors there. So could it be that the nausea effects are caused by uh- pituitary hormones that are changed? Because it does effect those. Is it disturbances in your hypothalamus? In your adrenal uh- hormones? Because then you can have this autonomic instability with your heart rate going, the sweats, and the nausea, and all that. ‘Cause they have been described and it’s very similar to the symptoms you get with Cyclic Vomiting Syndrome in children. So could there be the overlap right there? It’s really interesting. We don’t know. These cannabinoid receptors uh- in the preoptical area right behind the eyes have been involved in the hypothermic effects of cannabinoids. In other words, this feeling that- that they lower uh- body temperature. And impairment of physiologic thermal regulation, meaning your ability to control your temperature, provoked by cannabis use might account for the relief of symptoms with compulsive hot bathing. So could it be that there’s some dysregulation in your ability to manage temperature and going in a hot bath somehow compensates for that in marijuana use?

Tom H.: Oh, okay.

ZDoggMD: Yeah so it’s an interesting thought. Again, this is all speculation based on very small patient numbers using physiological first principles, but we just don’t know.

Tom H.: People in the comments are saying that, you know, they’re struggling to keep up with this as a medication since people are using it as a medication and they’ve kind of been stumbling on the hot shower thing on their own. Just anecdotally with patients.

ZDoggMD: Mm.

Tom H.: Seems to be the only thing that’s helping people in the hospital setting.

ZDoggMD: And I, you know, I think again patients find ways to treat themselves that work for them and-

Tom H.: What do you think is, you know, broad spectrum for this, what do you think of weed as a medicine?

ZDoggMD: … (head movement)

Tom H.: I know it’s, like, such a loaded question.

ZDoggMD: I mean I’ll tell you what I think. I think that for some people with the right physiology it helps with certain symptoms of certain things. It doesn’t cure anything. Alright?

Tom H.: Right.

ZDoggMD: Except for boredom.

Tom H.: Well, it seems to me that it- it can cure ordinary misery.

ZDoggMD: Right.

Tom H.: But nothing beyond that.

ZDoggMD: Boredom and angst.

Tom H.: Yeah.

ZDoggMD: So if you’re selling it as a cure for cancer, if you’re selling it as a cure for ANYthing, you’re probably wrong, but we can study it more. For SYMPTOMS, yes. It helps for certain people just like alcohol can help some people sleep and for most people it actually disrupts sleep. So it depends on who you are, what your physiology are, what receptors you are, what kind of brain you have. It’s- there’s no one size fits all. Should we study it? Absolutely. Should we legalize it? 100%. Because, the fact that we have alcohol and tobacco legal and not marijuana, all that does is create a thriving, you know, underground without us being able to study the drug, etcetera. So that- that’s MY two cents on- on marijuana. Umm… so the point of all this, really, is to say, “Okay, here’s a drug that a lot of people are touting as a cure all for stuff. Here’s this potential bad effect of this. If we see this effect in our patients, we should be aware of its possibility. And the idea that we might ask them to stop at least as a trial for a couple of months. See if they feel better but don’t just set them adrift. Give them medication and support to help them get off.” And then understand that the popular press will spin this a million different ways. And when you look at the primary data like we do, you realize it’s a small case series. There’s a lot of correlation, but that doesn’t- shut up, Siri. That doesn’t mean that there’s necessarily causation. So, again, smoke it if you got it, Tad.

(snickering)

ZDoggMD: Let’s read some comments. What do you think?

Tom H.: Let’s do it. Uh- let’s see-

Logan: Deb’s watching from the ER.

ZDoggMD: Nice.

Tom H.: She said she asked her nurse for a turkey sandwich and slippers and that ‘D’ drug.

ZDoggMD: Perfect. So, Deb, why are you in the ER? We hope you’re feeling better soon… Umm… “You need a bigger sample size. You need product strain information, product info. That would help.” Uh, Cynthia Ayers, I agree. Umm… let’s see. “I had a patient who took promethazine-” Phenergan uh- or is it Compazine. I forget now. I think promethazine is Phenergan. Umm… I always get them confused. Stupid generics. “To treat nausea that is weed caused. I bet he was feeling real great after that combo.” Yeah, I mean, when you’re chasing one drug with another drug, you know. This is like your classic chemo thing.

Tom H.: Dude, you know what we used to do in high school? We would- would dip the blunt in promethazine and then let it dry-

Logan: You were insane.

Tom H.: Then roll the weed. Then smoke it.

Logan: Whoo!

Tom H.: And you got soo high doin’ that. It was crazy.

ZDoggMD: You are the fucking biggest derelict I’ve ever met in my life. (laughter) You know, I did some shit, Tom Hinueber, but it’s like the tip of the iceberg compared to- (laughter) And that’s why I love having Tom because he’s like, “Well, you know that time that I smoked crack with that one hobo in Brooklyn?”

Tom H.: ‘Cause I bring you guys what they’re talkin’ about in the streets (laughter) what the kids’r doin’. (laughter) Ooo… what about fake weed? You know about the spice, Z?

(At same time) ZDoggMD: I don’t really know. Tom H.: And the truth is you don’t

Tom H.: -really know this because they keep changing the chemical composition.

ZDoggMD: Yup. I don’t trust it.

Tom H.: Yeah.

ZDoggMD: And you get- just, dude, it’s legal in so many places just fricking smoke the real thing if you’re gonna get baked. Umm… hot baths. Let’s see. “I like Epic, but more” Okay, I’m not gonna- not that tha- no Epic bashing. So other people want to talk about umm… Serotonin Syndrome and extrapyramidal symptoms. We’ll do that in a different show. “Love me some dumping syndrome.” Adam West. So dumping syndrome is where food hits the duodenum and for some reason it triggers this massive autonomic rush of feeling terrible and then you get the squirts.

ZDoggMD: Well here’s an interesting thing. So in Canada, they did a trial on this particular variety of shrew. Uh- wh- it’s called a Musk Shrew. Which they onl- apparently the Canadians have that kind of shit. (laughter) And they’re like, “Aye, is that a Musk Shrew, aye?”

ZDoggMD: “Plus they have little human faces so we kinda think they- they’re pretty close to humans, aye?” (laughter) Umm… so this Musk Shrew, they would give it a shit ton of cannabis and it would puke.
Tom H.: Hm.

ZDoggMD: If you did it regularly. So they were able to reproduce at least some component of this in the Musk Shrew model which… I did not know existed until today.

Tom H.: Jason says, “So if we have our daughter stop smoking she’s going to need something like Zofran and an anti-anxiety medication?”

ZDoggMD: (sigh) It might- it might- she might need that. She might not. It might be very short term. And, again, I’m not a doc- I’m not a- (laughter) I was gonna say I’m not a-

(At same time) ZDoggMD: doctor. Logan: I’m not a doctor. (laughter)

ZDoggMD: Oh, shit! I gave it away! (laughter)

(At same time) Logan: Now they know. They know, Z. Tom H.: I’m not a real doctor you guys. (laughter)

ZDoggMD: I’m not her doctor and this is not medical advice. This is infotainment. Umm… she should see her doctor and talk about how to transition off marijuana and see if it helps.

Tom H.: Right.

ZDoggMD: That’s the correct answer.

Tom H.: Just anecdotally, though, like, whatever you’re going to prescribe, it’s not, like, “Take Zofran for a month, then take benzos for a month. Then-”

ZDoggMD: No.

(At same time) ZDoggMD: No, no, no, no. Tom H.: And now you get hooked on benzos.

ZDoggMD: You overlap it.

Tom H.: Right.

ZDoggMD: So you want to start that and then, at least according to the articles that I read-

Tom H.: Maybe a few days.

ZDoggMD: Right, right.

Tom H.: To help with the transitional period.

ZDoggMD: Right.

Tom H.: And then you’re off that-

(At same time) ZDoggMD: And you- Tom H.: all.

ZDoggMD: -might not need it very long.

Tom H.: Yeah.

ZDoggMD: And in fact the hope is that you don’t because you don’t want to su-

Tom H.: Oh, but weed’s not addictive, Z! It’s not even addictive, man.

Tom H.: Listen, bro. People who get addicted to weed, they’re just psychologically weak. No. It’s addictive. Jesus Christ. (laughter) Look around at all the people who are addicted to it!

Logan: You seen the kids snortin’ uh- chocolate?

ZDoggMD: Yeah! That’s not a good idea. You know Charlie- uh- Willy Wonka did that and look at him.

Tom H.: Exactly.

ZDoggMD: Dude’s effed up. He had a glass elevator and shit. So uh- (laughter) “My fiancé” says Jennifer Marie, “has PTSD rea- pretty bad and it helped a lot of his symptoms for awhile now. He finally sleeps through the night. Hasn’t had the hypervigilance nearly as bad as he usually does.” So for some people- some people report improvement in PTSD. Again, you’d need a randomized controlled trial. Uh- but, you know there are other uh- experimental drugs for PTSD like ketamine and other types of therapy. Including MDMA, ecstasy.

ZDoggMD: Ketamine, MDMA, these are all preliminary and it comes with the talk therapy that goes with it. So you’re sitting there with a blindfold on.

Tom H.: Yeah.

ZDoggMD: They’re talking you through this thing and, in many ways, uh- you know, people report they relive- they go back to the scene of the original trauma and they reframe it and they find a sense of meaning in it.

Tom H.: Right.

ZDoggMD: And they find some love to be found in the- in the horrible event. And that- ecstasy, anyone who has done ecstasy- It depends. Everyone has different experiences with it, right? But it-

ZDoggMD: We’ll get some experts on PTSD on the show because there’s been enough interest in it and it’s a enough of a problem, enough cause for suffering. Not just in the patient, but in their family, extended and friends-

Tom H.: Oh, dude, I have a buddy who’s a scout sniper and he told me weed is the only thing that stopped him from killing himself.

ZDoggMD: Yeah.

Tom H.: So, if it’s helping? Great! Like, keep using it.

ZDoggMD: Plus, then you can listen to Cypress Hill and find that they don’t actually suck as bad as you thought. (laughter)

ZDoggMD: (singing) Hits from the bong deh na dung dunk dunk duh nuh. Hits from the bong. Pick it. Pack it. Fire it up. Come along and take yer hits from the bong. Put your blunt down just for a second-

(At same time) ZDoggMD: Dope- Tom H.: Hey-

Tom H.: Real quick. We have- we definitely have people who have teenagers on the show. So, you know, while we’re saying weed is, you know, not that bad etcetera, etcetera. What point would you- let your own children smoke weed?

ZDoggMD: Hmm hmm-

Tom H.: And like, you know, not come down too harsh on them?

ZDoggMD: There is… considerable early data that says that smoking cannabis during adolescence leads to permanent reconfigurations of the brain that may not be positive. Now you always have to worry that this is more “reefer madness” science because they did similar studies with MDMA. Saying it changes spinal neurons and so on. And these were rat studies and how much they translate I don’t know. But I personally am nervous enough about it in adolescents with growing brains, that I would say, “Don’t. Just wait. You can get high as fuck when you’re twenty-five or thirty. Don’t do it when your brain is growing. Because it’s prob-ab-ly going to change stuff in a way you can’t predict.” We just don’t know, right? And, again, no reefer madness… but dare to keep kids off drugs.

Tom H.: ‘Cept, I did it. And now I’m a bit coin millionaire. So (tongue click) suck it, guidance counselors.
ZDoggMD: I don’t know if bit coin thousandaire counts as millionaire, but I think if you round up. (laughter) Sure. (laughter)

Tom H.: Uh- uh Allen says, “EMDR has been found to be very useful with PTSD. There’s another version called IEMT which may well be even better. See the work of Andrew Austin, psychiatrist nurse in England.” So, yeah, EMDR is- it’s just about rapidly moving the eye. They put you in this sorta like cone thing, I think and then there’s- there’s uh dots you’re supposed to follow-

ZDoggMD: Yeah, yeah.

Tom H.: And as you’re following the dots with your eye, you receive talk therapy. And it helps you sort of reset a trauma from the past.

ZDoggMD: The visual and stuff. Well, Monica Winter says, EMDR didn’t work for her. “It seems to work for some personality types. Not for others.” So there’s no one size fits all. So Allison McClay says, she did EMDR for ADHD and “it’s good for real trauma, but it doesn’t work for ADHD.”

Tom H.: Mm.

ZDoggMD: And then Christine McGrory says, “It’s time to call the code on this. Good night, Zubin, Tom, and Logan. #LoganHadNoHashtagTonight”

Logan: Reefer madness, y’all. (laughter)

ZDoggMD: Reefer madness!

Tom H.: You know what? The hashtag’s inside yourself, you guys.

Logan: It’s inside of you.

ZDoggMD: Look deep inside… and you’ll find your own hashtag. And that hashtag may be #SmokeItAllDayE’ryDay. But I don’t recommend it. Guys, thank you for joining us again for a Tribe Teach! Hopefully this was useful to you. If it was, hit share. Spread the word. We’re doing Tribe Teach every now and again. Annd- if you love us, like I know you love us, hit us up on Patreon. We’ve gotten a lot of donations recently. They help us a lot to support the show. They pay our expenses and our bills and all the costs that we have to bring this WONDERFUL programming to you. Why do I sound like a public radio host during a telethon?

I think it is interesting to note, from all the literature I have read,that not one case of CHS has occurred in a patient older than 50. Also, that chronic users have smoked for chronically for at least one year before this conditions presents.